Provider Demographics
NPI:1679689541
Name:DECATUR VEIN CLINIC, MICHIGAN, PC
Entity Type:Organization
Organization Name:DECATUR VEIN CLINIC, MICHIGAN, PC
Other - Org Name:DECATUR VEIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:DECATUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-218-2800
Mailing Address - Street 1:PO BOX 4237
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46082-4237
Mailing Address - Country:US
Mailing Address - Phone:317-218-2800
Mailing Address - Fax:317-818-8919
Practice Address - Street 1:1669 HAMILTON RD
Practice Address - Street 2:SUITE 220
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1956
Practice Address - Country:US
Practice Address - Phone:517-381-1000
Practice Address - Fax:517-381-8751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N1680Medicare ID - Type UnspecifiedGROUP MEDICARE#